What is Panic Disorder?
Panic disorder is a medical condition that causes a person to experience recurrent panic attacks and persistent concern about having future attacks. A panic attack is a brief period of intense fear or discomfort accompanied by distinct symptoms. An attack usually comes to an end gradually on its own and rarely lasts beyond 10 minutes. Symptoms may include heart palpitations, chest discomfort, sweating, trembling, nausea, numbness or tingling, hot/cold flashes, feeling short of breath, feeling dizzy, feeling disconnected from oneself, fear of losing control, or fear of dying. These symptoms, which feel very real to the person, likely reflect the body’s intense response to a strong “fight or flight” signal that is beyond the person’s conscious control.
Unlike the occasional, mild worries that children often experience, panic disorder may dramatically affect a child's life by interrupting his or her normal activities when an episode occurs or when the child becomes preoccupied with worry about possible future panic attacks. Some individuals with panic disorder avoid places where they think panic attacks might occur, or worry about being trapped in places where help might be unavailable if an attack occurred. This behavior of worrying about certain places or avoiding them is called agoraphobia. Young people who have panic disorder with agoraphobia most often avoid places with large numbers of unfamiliar people, such as school auditoriums, large parties, and restaurants.
Many children and adolescents have an isolated panic attack, which does not require intervention because it does not recur. A smaller number of children and adolescents develop panic disorder. The tendency to develop panic disorder involves complex genetic and environmental factors. Panic disorder affects as many as five percent of adolescents, and is less common in younger children. top
What Does Panic Disorder Look Like in Children and Adolescents?
Panic disorder often looks different in young people than in adults, because children tend to report the physical symptoms accompanying panic attacks rather than the psychological symptoms. Children having a panic attack may appear to be suddenly frightened or upset with no easily identified explanation. This behavior is often confusing to others.
Sometimes children having a panic attack incorrectly explain their symptoms as a response to an external trigger (for example,"It started when I saw that dog"). These children, particularly if they are very young, may not be able to articulate the intense fears they experience during a panic attack. Adolescents are generally better able to describe what they experience, particularly after a panic attack has ended.
Panic disorder is distinguished by the unpredictability of the panic attacks. If a child is predictably frightened by a particular situation (such as meeting a new person) or predictably panics when seeing something he or she finds upsetting (such as a spider), the child may have a phobia rather than panic disorder. Phobias are intense fears predictably triggered by particular situations or objects. Phobias include social phobia (associated with intense fear when exposed to new people) and specific phobia (associated with intense fear when exposed to a particular situation or object).
If left untreated, panic disorder can lead to considerable worry or limitations in other areas of the child's life. Peer relationships, school functioning, and family functioning may suffer, or depression may develop. In some situations, in response to extreme anxiety, social isolation, or limited activities, a child may develop thoughts of self-harm or not wanting to be alive. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top
► At Home
Children with panic disorder may feel less pressure at home than at school to hide their symptoms. As a result, they may appear to have more symptoms at home, whether or not this is really the case. Symptoms may include a combination of those listed below.
- Recurrent "out of the blue" episodes of fear or physical discomfort that are brief. Typically, panic attacks reach their maximum in 10 minutes.
- Recurrent episodes that are accompanied by physical symptoms, such as fast heart rate, difficulty breathing, chest discomfort, choking sensation, dizziness or faintness, trembling, sweating, nausea, or hot/cold flashes
- Recurrent episodes that may include psychological symptoms or worries such as the fear of losing control, the fear of "going crazy," or the fear of dying. Additional symptoms include feeling detached from one's body or feeling detached from reality.
- Persistent worry about future panic attacks
- Fear of being trapped in places or situations where escape might be difficult or embarrassing, particularly if a panic attack occurs. Such places include crowded areas, public places (shopping malls, restaurants), bridges, or enclosed spaces such as elevators, cars, or trains. Standing alone or in line may also be distressing.
- Avoidance of places where the child worries an attack may occur or where help may not be available. Some children may be able to go to these places only in the company of another person.
- Difficulty explaining unusual behavior. Children with panic disorder may not be able to explain what their symptoms or worries are or why they feel compelled to avoid certain places.
- Feeling out of control, uncertain, and frightened by the unpredictability of panic attacks
- Low self-esteem, isolation from peers, and reluctance to participate in activities
- Experimentation with alcohol or drugs as a way to reduce suffering. Drugs and alcohol can themselves produce or worsen panic symptoms.
- Depression or thoughts of not wanting to be alive may develop when children mistakenly believe there are no interventions to reduce their panic symptoms top
► At School
A student with panic disorder may have panic attacks at school, though the child may try to hide symptoms while at school. As a result, a child may appear to have more symptoms at home than at school. A child may also be reluctant or unable to describe attacks, which may lead to confusion at school regarding the nature of the child's symptoms.
At school, a child with panic disorder may have a combination of the symptoms listed below.
- Recurrent "out of the blue" panic attacks
- Repeated, sudden interruption of activities without clear explanation. Children and adolescents may need adult assistance to understand and express their symptoms.
- Low self-esteem in social and academic activities
- Difficulty concentrating due to persistent worry, which may affect a variety of school activities, from following directions and completing assignments to paying attention
- Difficulty separating from parents, trouble transitioning from home to school, reluctance attending school, or avoiding play time with peers
- Other conditions, such as Attention Deficit/Hyperactivity
Disorder (ADHD), may also be present, compounding learning
difficulties. Having one mental health condition does not "inoculate"
the child from having other conditions as well.
- Additional anxiety disorders, such as social phobia, separation anxiety and generalized anxiety. Anxiety disorders may not be recognized both because children may try to hide symptoms and because their symptoms are experienced internally and not easily seen.
- Learning disorders may co-exist and should not be overlooked
in this population. A child's difficulties in school should not
be presumed to be due entirely to panic disorder. If the child
still has academic difficulty after symptoms are treated, an educational
evaluation for a learning disorder should be considered. A child's
repeated reluctance to attend school may be an indicator of an
undiagnosed learning disability.
- Medication side effects that can interfere with school performance. Once a child is receiving treatment for symptoms, new mood changes or behaviors should be discussed with parents, as they can reflect medication side effects. top
► At the Doctor's Office
A child's symptoms of panic disorder often are not seen during an office visit. Clinicians may benefit from talking with parents, school staff, and other important caregivers to evaluate a child's overall functioning and to determine the underlying cause of the symptoms.
Clinicians may have to deal with some of the following challenges in diagnosing and treating a child or adolescent with panic disorder.
- Symptoms vary over time and their appearance changes as a child grows. A clinician may need to see a child over time to determine the appropriate diagnosis.
- Other conditions, particularly other anxiety disorders, may look like panic disorder. These conditions include specific phobias (panic-like symptoms triggered repeatedly by the same object or situation, such as spiders or flying), social phobia (panic-like symptoms triggered by social situations), and separation anxiety (panic-like symptoms triggered by separation from a caregiver). The symptoms of mood disorders can also be similar to the symptoms of panic disorder.
- Medical conditions can cause panic attacks. These conditions include hyperthyroidism, hyperparathyroidism, cardiac disorders, seizure disorders, and vestibular or inner-ear disorders. Relevant laboratory tests and physical examinations may be helpful when a child has panic symptoms, particularly if the symptoms are severe, unresponsive to interventions, or if they occur in a family with no history of anxiety disorders.
- Panic disorder is probably under-diagnosed in children and adolescents, as youngsters' symptoms are often ascribed to other conditions
- Young people are often embarrassed about their symptoms and may not volunteer information. Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge.
- Children may be unaware, or unwilling to admit, that their behavior may indicate symptoms of a disorder
- Families may need to be coached about what they can
reasonably expect from their child. Children who suffer from panic
disorder will benefit if their family understands that therapy
and medicines may reduce, but may not cure, symptoms. top
How is Panic Disorder Treated?
Panic disorder is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family.
These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and school that reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and treatment professionals optimizes the care and quality of life for the child with panic disorder. top
► Psychological Interventions (Counseling)
- Counseling can help children with panic disorder, and everyone around them, to understand that panic disorder symptoms are caused by an illness with complex genetic and environmental origins--not by flawed attitude or personality. Counseling can also reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.
- Individual psychotherapy is generally recommended as the first line of treatment for children and adolescents with panic disorder. Children with panic disorder may carry a sense of failure, as if the illness was their fault. Individual psychotherapy can help reduce symptoms, and can help young people to become aware of and address their feelings of failure and self-blame.
- Cognitive Behavior Therapy (CBT) can teach young people new skills to reduce anxiety that can lead to panic attacks. In CBT, a child or adolescent is helped to become aware of, and to describe, negative thoughts, feelings or reactions.
A trained clinician guides the child to think of new, more positive alternatives, including techniques for anticipating and preventing the emergence of “full-blown” panic attacks. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon well-researched practices that have helped many adults with panic disorder.
- Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
- Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting.
- School-based counseling can be effective in helping a child with panic disorder navigate the social, behavioral, and academic demands of the school setting. top
► Biological Interventions (Medicines)
While psychotherapy may be sufficient to treat some children with
panic disorder, other children's symptoms do not improve significantly
with psychotherapy alone. These children may benefit from medications.
The U.S. Food and Drug Administration (FDA) has not approved specific
medications for the treatment of panic disorder in children and
adolescents. However, medications approved by the FDA for other
uses and age groups are prescribed for young people with panic disorder.
The FDA allows doctors to use their best judgment to prescribe medication
for conditions for which the medication has not specifically been approved.
The following medications are commonly prescribed for children
and adolescents with panic disorder:
- Antidepressants. Antidepressants are commonly prescribed
to treat the symptoms of panic disorder. The most commonly prescribed
antidepressants, including Celexa, Lexapro, Luvox, Paxil, Prozac
(fluoxetine), and Zoloft, belong to a group of medications called
Selective Serotonin Reuptake Inhibitors, or SSRI's.
- Benzodiazepines. Benzodiazepines such as Ativan, Klonopin,
and Xanax also may be prescribed, in conjunction with SSRI's,
for treating more severe symptoms for a brief period of time.
While benzodiazepines usually take effect in the first week, antidepressants
generally begin to be effective in reducing symptoms after they
are taken regularly for at least 2-4 weeks. Fully 12 weeks may be
required in order to determine whether the medication is going to
be effective for a particular individual. Medications should only
be started, stopped, or adjusted under the direct supervision of
a trained clinician.
There is no "best" medicine to treat panic disorder, and it is
important to remember that medicines usually reduce rather than
eliminate symptoms. Different medicines or dosages may be needed
at different times in a child's life or to address the emergence
of particular symptoms. Successful treatment requires taking medicine
daily as prescribed, allowing time for the medicine to work, and
monitoring for both effectiveness and side effects. The family,
clinician and school should maintain frequent communication to ensure
that medications are working as intended and to monitor and manage
The following cautions should be observed when any child or adolescent
is treated with antidepressants.
- Benefits and risks should be evaluated. Questions have
arisen about whether antidepressants can cause some children or
adolescents to have suicidal thoughts. The evidence to date shows
that antidepressants, when carefully monitored, have safely helped
many children and adolescents. The latest reports on this issue
from the U.S. Food and Drug Administration can be found on its
web site at www.fda.gov.
Consideration of any medicine deserves a discussion with the prescribing
clinician about its risks and benefits.
- Careful monitoring is recommended for any child receiving
medication. Though most side effects occur soon after starting
a medicine, adverse reactions can occur months after medicines
are introduced. Agitation, restlessness, increased irritability,
or comments about self-harm should be addressed immediately with
the clinician if any of these symptoms emerge after the child
starts an antidepressant. Frequent follow-up (weekly for the first
month) is now advocated by the FDA for children starting an antidepressant.
- Some children who have panic disorder may also have bipolar
disorder. In some individuals with bipolar disorder, antidepressants
may initially improve depressive symptoms but can sometimes worsen
manic symptoms. While antidepressants do not "cause" bipolar
disorder, they can unmask or worsen manic symptoms.
Helpful information about specific medications can be found at
(click on "Drug Information") and in the book Straight Talk About
Psychiatric Medications for Kids (Revised Edition) by Timothy
E. Wilens, MD. top
► Interventions at Home
At home, as well as at school, the responses and interventions
of caring adults can help a child or adolescent to manage difficult
- Understand the illness. Understanding the nature of
panic disorder and how it is experienced by the child will help
parents sympathize with a child's struggles.
- Listen to the child's feelings. Isolation can foster
low self-esteem and depression in young people with panic disorder.
The simple experience of being listened to empathically, without
receiving advice, may have a powerful and helpful effect.
- Keep calm and be a comforting presence during panic attacks.
If a child sees a parent is able to remain calm, the child can
model the parent's attitude. Helping the child get through a panic
attack and return to activities will encourage continued participation
in healthy activities. Over the course of several minutes each
episode usually comes to an end fairly quickly on its own, so
the best approach for parents is to maintain composure. Parents
should not expect they can intervene to stop the episode while
it is occurring.
- Gently help the child remember that he or she survived the
last panic attack. This may assist the child in reducing anxiety
and may even shorten a subsequent panic attack.
- Anticipate transition points. The unpredictability of
panic attacks may cause a child to become apprehensive at transition
points such as going to school or meeting friends for play.
- Teach relaxation techniques. Relaxation techniques include
deep breathing, counting to 10, or visualizing a soothing place.
Teaching children how to relax will empower them to develop mastery
over symptoms and improve a sense of control over their body.
- Praise the child's efforts to address symptoms. Young people often feel that they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised. For example, decreasing the length of time the panic attack occurs, and reducing the fright the child feels during the panic attack, are both positive steps toward controlling panic disorder. top
► Interventions at School
There are many ways that schools can help a child with panic disorder succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifications, and school strategies include the following:
- Establish check-ins on arrival to see if the child can succeed in certain classes that day
- Allow the student to “cue” teachers or staff if a panic attack is occurring so that the student can go to a less stressful (or embarrassing) environment. At the same time, reward the student for efforts to remain in class and control the panic attacks.
- Provide more time to complete certain types of assignments
- Accommodate late arrival due to symptoms at home
- Adjust the homework load to prevent the child from becoming overwhelmed. Academic stressors, along with other stresses, may aggravate symptoms.
- Develop relaxation techniques to help reduce anxiety at school. Employing techniques developed at home can also be useful.
- Identify a safe place where the child may go to reduce anxiety during stressful periods. Developing guidelines for its appropriate use will help both the student and staff.
- Encourage the child to develop helpful interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve.
- Anticipate issues such as school avoidance if there are unresolved social and/or academic problems
- Provide assistance with peer interactions. An adult's help may be very beneficial for both the child and his or her peers.
- Be aware that transitions may be difficult for the child. When a child with panic disorder refuses to follow directions, for example, the reason may be symptoms of anxiety rather than intentional oppositionality.
- Please click on School-Based Interventions for a more complete list of school accommodations
for children with panic disorder
Flexibility and a supportive environment are essential for a student
with panic disorder to achieve success in school. School faculty
and parents together may be able to identify patterns of difficulty
and develop remedies to reduce a child's challenges at these times. top
Many online resources and books are available to help parents,
clinicians, and educators learn more about children and adolescents
with panic disorder. Click here for
a wide selection of resources top
Information provided above on panic disorder draws from sources
American Academy of Child and Adolescent Psychiatry, Facts for
Families: Panic Disorder in Children and Adolescents. Washington,
DC: American Academy of Child and Adolescent Psychiatry, 2000
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition. Washington, DC: American Psychiatric Association, 1994
Bostic, JQ, Bagnell, A. School Consultation. In Kaplan BJ, Sadock VA. Comprehensive Textbook of Psychiatry, 8 th edition. Philadelphia: Lippincott Williams and Wilkins, 2004
Dulcan, MK, Martini DR. Concise Guide to Child and Adolescent Psychiatry, 2 nd Edition. Washington, DC: American Psychiatric Association, 1999
Lewis, Melvin (ed.). Child and Adolescent Psychiatry: A comprehensive Textbook, 3 rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002 top